Is there a need for urologist assistance in the management of abnormally invasive placenta?

To the Editor,

We read with great interest the letter by Professors Matsubara and Takahashi, and we thank them for their valuable comments [1]. They have clearly read and dissected our paper [2] very thoroughly and they question whether it is even possible to firmly point out which part of our formal multidisciplinary approach really brought about the striking differences in blood loss, transfusion rate and complication rate in cases of abnormally invasive placenta (AIP). Professors Matsubara and Takahashi count several (six) important components of our strategy and they speculate that a better outcome might be a result of a total effect of these factors.

We agree. In fact, in our paper we state that ‘This retrospective study shows that the antenatal diagnosis of AIP in combination with standardized multidisciplinary management, and the introduction of a modified surgical approach by a urologist, significantly decreases blood loss and blood transfusion rate’ but, in accordance with the contention of Professors Matsubara and Takahashi, we cannot with certainty emphasize which of the components of our strategy was the most important or if the improved results were brought about by a combination of all or several of them.

The technique adopted by us and by others [3], comprising extensive dissection before delivery allowing for a rapid control of hemorrhage, is partly questioned by Professors Matsubara and Takahashi. They claim that intentional cystotomy before delivery usually causes massive bleeding. However, here we are clearly in disagreement. On the contrary, we are of the opinion that a perfectly well-controlled intentional cystotomy yields no bleeding at all. Nevertheless, we would like to stress the word ‘controlled’. This means cutting through healthy and unengaged bladder tissue and completely staying away from the vascularization of the AIP. This requires experience but it is by no means impossible. But is it unnecessary? Perhaps it is of no obvious advantage in most cases but, in fact, very recently we encountered a case of partial detachment of an AIP directly after delivery. The bleeding that occurred was, as anticipated, difficult to control but this did not matter very much, since the meticulous preparation before delivery, including intentional cystotomy, allowed for a very fast and uneventful hysterectomy.

In summary, we feel comfortable with upholding our conclusion, that ‘Prenatal diagnosis and adherence to a standardized multidisciplinary approach in the management of women with AIP result in a striking improvement in terms of blood loss reduction, the need for transfusion and the risk of postoperative complications’. We also believe that involving an experienced urologist as a member of the multidisciplinary team is clearly advantageous.

Disclosure statement

No potential conflict of interest was reported by the author.